Elsevier

Surgery

Volume 167, Issue 6, June 2020, Pages 950-956
Surgery

Biliary
Postoperative infectious complications caused by multidrug-resistant pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection

https://doi.org/10.1016/j.surg.2020.02.015Get rights and content

Abstract

Background

Few reports have addressed postoperative infectious complications caused by multidrug-resistant pathogens. The aim of this study was to review the surgical outcomes of patients undergoing major hepatectomy with extrahepatic bile duct resection and to clarify the incidence of and the risk factors for postoperative infectious complications caused by multidrug-resistant pathogens.

Methods

Medical records of consecutive patients who underwent major hepatectomy with extrahepatic bile duct resection between 2006 and 2017 were retrospectively reviewed.

Results

Among 620 study patients, 219 had postoperative infectious complications, including 62 (10.0%) with postoperative infectious complications caused by multidrug-resistant pathogens. The mortality of the 62 patients with postoperative infectious complications caused by multidrug-resistant pathogens was higher (n = 8, 12.9%) than that in the 157 patients with postoperative infectious complications caused by non-multidrug-resistant pathogens(n = 2, 1.3%) (P < .001). With multivariate analysis, the presence of preoperative cholangitis, the extent of liver resection more than 50%, operative time longer than 600 minutes, the amount of blood loss more than 1500 mL, and the presence of postoperative infectious complications caused by multidrug-resistant pathogens were identified as independent risk factors for postoperative death. The presence of multidrug-resistant pathogens in preoperative bile culture, the amount of blood loss greater than 1500 mL, the presence of bile leakage, and pancreatic fistula were identified as independent risk factors for postoperative infectious complications caused by multidrug-resistant pathogens.

Conclusion

The incidence of postoperative infectious complications caused by multidrug-resistant pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection is high, approximately 10%. This troublesome complication is closely associated with postoperative death. Thus, preventing postoperative infectious complications caused by multidrug-resistant pathogens is an urgent task to improve surgical outcome after major hepatectomy with extrahepatic bile duct resection.

Introduction

Despite recent advances in diagnostic and surgical techniques and the refinement of perioperative management,1,2 hepatectomy with extrahepatic bile duct resection for perihilar malignancy remains challenging and is associated with high morbidity and mortality rates.3,4 In particular, postoperative infectious complication (POIC) is a major cause of morbidity and mortality.

Since the 1980s, various drug-resistant pathogens have emerged in the field of medicine.5, 6, 7, 8 Currently, pathogenic bacteria have increasingly gained resistance to multiple antimicrobial agents, and these multidrug-resistant (MDR) bacteria have become a significant public health threat7,8 In most patients with perihilar malignancy, preoperative biliary drainage is necessary, which leads to colonized/infected bile.9,10 We reported elsewhere10 that the incidence of preoperative biliary colonization/infection caused by MDR pathogens was 6.4% in patients undergoing surgery for perihilar cholangiocarcinoma and showed that major hepatectomy with extrahepatic bile duct resection can be performed with acceptable rates of morbidity and mortality, using appropriate antibiotic prophylaxis, even in patients with biliary colonization/infection caused by MDR pathogens. However, the impact of POIC caused by MDR pathogens (MDR-POIC) on the postoperative course of hepatectomy with extrahepatic bile duct resection has not been addressed. MDR-POIC after major surgery leads to a troublesome postoperative course because effective antimicrobial agents are limited.

The aim of the present study was to review the surgical outcome of patients undergoing major hepatectomy with extrahepatic bile duct resection with special attention to MDR-POIC and to clarify the incidence of and the risk factors for this difficult complication.

Section snippets

Patients

Medical records of consecutive patients (both male and female) who underwent combined liver and extrahepatic bile duct resection with intrahepatic cholangiojejunostomy at the First Department of Surgery, Nagoya University Hospital, Nagoya, Japan, between January 2006 and December 2017 were retrospectively reviewed with a focus on MDR-POIC. Patients who underwent hepatopancreatoduodenectomy were excluded.11 This study was approved by the Human Research Review Committee of Nagoya University

Study patients

During the 12-year study period, 620 consecutive patients, including 406 (65.5%) men and 214 women, underwent hepatectomy with extrahepatic bile duct resection. The median age was 67 years (22–89 years). Of these patients, 523 (84.4%) had cholangiocarcinoma, 48 (7.7%) had gallbladder cancer, and 49 (7.9%) had other diseases. A total of 518 (83.5%) patients had undergone preoperative biliary drainage, and 410 (66.1%) had colonized/infected bile before surgery. The types of hepatectomy performed

Discussion

In the present series of 620 patients who underwent major hepatectomy with extrahepatic bile duct resection, 219 (35.3%) patients developed POIC: 157 (25.3%) had non-MDR-POIC, and 62 (10.0%) had MDR-POIC. The latter patients, compared with the former patients, exhibited an unfavorable postoperative course and high mortality rate. These observations indicate that MDR-POIC has a substantial negative impact on short-term outcomes. Thus, preventing MDR-POIC is an urgent task to improve surgical

Funding/Support

No organizations funded our research.

Conflict of interest/Disclosure

None of the authors have received financial support or have direct or indirect personal relationships with people or organizations that could potentially and inappropriately influence their work and conclusions.

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